CMS-1500 Completion Guide

This information is intended to support appropriate claims completion when submitting claims for Lexiscan. It is important to confirm payer-specific claims completion requirements and accepted procedure and diagnosis codes before submitting claims. For general billing instructions on the CMS-1500, reference the appropriate Medicare Claims Processing Manual1.

Items 17, 17a, 17b Name of Referring Provider
  • Document the name, UPIN, and NPI of the physician requesting or ordering the services for the patient
  • The NPI of the referring physician is required information in 17B
Item 19 Reserved for Local Use
  • Used to capture additional data to support claims review, including:
    • Concise descriptions of services billed using unlisted procedure codes
    • Applicable modifiers if multiple modifiers are required for a CPT2 or HCPCS code
    • Sometimes used to report prior authorization numbers for private payers and Medicaid plans
Item 21 Diagnosis Codes
  • Report appropriate code(s) based on patient diagnoses and conditions according to medical record documentation
  • Codes should be entered in priority order and to the highest level of specificity
Item 23 Prior Authorization Number
  • Used for various purposes by Medicare
  • Sometimes used to report prior authorization numbers for private payers and Medicaid plans
Item 24 Shaded Portion
  • If required by state for Medicaid drug rebate processes, may be used to capture NDC for Lexiscan or other drugs used during patient encounter
    • For Lexiscan, enter "N4" followed by 11-digit NDC; for example, to report use of one single-dose, prefilled syringe of Lexiscan: N400469650189
Item 24D Procedures, Services, or Supplies
  • Report appropriate procedure or drug codes based on services provided during patient encounter according to medical record documentation
  • Up to 4 modifiers can be reported following the CPT or HCPCS code
  • Include J2785 to report use of Lexiscan
  • Some payers may require the cardiovascular nuclear medicine code, the radionuclide, Lexiscan, and the cardiac stress test code to be billed on the same claim
Item 24E Diagnosis Pointer
  • Report the number (1,2,3, or 4) corresponding to the diagnosis code from Item 23 that is most relevant to the service or procedure described
Item 24G Days or Units
  • Report the number of times services or procedures being reported were performed during the encounter according to medical record documentation
  • To represent use of one entire prefilled syringe of Lexiscan, report 4 units in this field
Item 24J Rendering Provider ID
  • Document the NPI of the physician rendering services to the patient in the unshaded portion
Item 32a NPI
  • Document the NPI of the service facility
Item 33a NPI
  • Document the NPI of the billing provider or group

1. http://www.cms.hhs.gov/Manuals/IOM/list.asp

2. Current Procedural Terminology (CPT), Professional Edition, 2011. American Medical Association, 2010. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no responsibility for the data contained herein. CPT is a registered trademark of the American Medical Association.

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